VIRTUA HEALTH MANUAL TITLE Children’s Care Manual
POLICY NAME
INFANT/CHILD SECURITY GUIDELINES & PROCEDURES
MANUAL OWNER MCH Specialty Practice Council
DATE OF ISSUE
REVIEW INTERVAL
REVIEWED / APPROVED BY: (Committees) MCH SPECIALTY PRACTICE COUNCIL
36 Months
10/2011
DATE OF LAST REVIEW 2/13, 08/14
DATE OF REVISION
EFFECTIVE DATE
MHBC: 4/99, WJHS:12/96, VIR: 5/03, 4/07, 2/08, 2/13
11/2011
POLICY: Hospital personnel are key in preventing infant/child abduction. Prevention includes assuring unit security, parent education, vigilance of staff, and prompt response in the case of a missing infant/child. PHYSICIAN ORDER REQUIRED: No CONSENT REQUIRED:
No
WHO MAY PERFORM:
RN, MST
WHO MAY ASSIST:
Security and all hospital personnel
CURRENT EVIDENCE: AWHONN Templates for protocols and procedures for Maternity Services (2002). Joint Commission on Accreditation of Healthcare Organizations (1999, April). Infant Abductions. Sentinel Event Alert, 9, Oakbrook Terrace, IL: Author. Shogan, M.G. (2002) Emergency Management Plan for Newborn Abduction. JOGNN, 31, 340-346. National Center for Missing and Exploited Children for Healthcare Professionals: Guidelines on Prevention of and Response to Infant Abductions, 8th Ed. June (2005) Maintaining Infant/Child Safety: Training of staff 1. Staff will complete yearly competency on education for Infant/child safety and the prevention of Infant/child abductions. 2. “Mock” drills will be performed and evaluated annually for staff compliance with recognizing a possible abduction. Training of Parents 1. Parents will receive guidelines for preventing infant abductions during upon admission, at postpartum instruction and upon discharge. Proactive measures 1. A sample of the infants cord blood and any other blood specimens will be stored until at least a day after infant’s discharge. ( check with lab) 2. All visitors will be asked which mother they are here to visit. 3. Before discharge of infant, confirm the person taking the infant home has matching ID band with infant. 4. Legal documents will be reviewed and verified before infant is discharged to someone other than biological parents or guardian. 5. Hospital staff will always walk the mother and baby to the car at the time of discharge. (To infant car seat technition)
Pg. 1 of 12
VIRTUA HEALTH MANUAL TITLE Children’s Care Manual
POLICY NAME
INFANT/CHILD SECURITY GUIDELINES & PROCEDURES
MANUAL OWNER MCH Specialty Practice Council
DATE OF ISSUE
REVIEW INTERVAL
REVIEWED / APPROVED BY: (Committees) MCH SPECIALTY PRACTICE COUNCIL
36 Months
10/2011
DATE OF LAST REVIEW 2/13, 08/14
DATE OF REVISION
EFFECTIVE DATE
MHBC: 4/99, WJHS:12/96, VIR: 5/03, 4/07, 2/08, 2/13
11/2011
Use of Infant Security System: 1. VOORHEES DIVISION: All well newborn, NICU pts in open cribs unless medically inappropriate, children in the inpatient Pediatric Unit under the age of 17, and appropriate PICU level patients as determined by the nursing and medical staff will be monitored. MEMORIAL DIVISION: All well newborn patients, Inpatient Pediatric Pavilion patients under the age of 17, and any SCN babies as deemed appropriate will be monitored 2. Attach and secure, numbered security tag to infant. Mother and father/significant other should receive an identically numbered ID bands as the infant. 3. The infant/child safety transponder will be initiated upon admission and monitored via central security terminal and unit based terminals in the MCH division. (See Appendix 1: Hugs Infant Security System Initiation and Maintenance) 4. If the infant/child needs to leave the floor and transponder needs to be placed into transport mode. A staff member or parent will remain with the infant/child at all times until returned to the unit and transponder is reactivated. The infant should always be placed in direct line of sight supervision. The infant’s band needs to be confirmed with the Mother’s band before transportation. ( not on way out of themothers room) 5. Staff should remain alert to visitors on unit at all times. Look for those who match typical abductor profiles (See attached table 1: Abductor Profile). Be assertive when seeing strangers on the unit. 6. Staff will wear up-to-date, conspicuous, photo identification at all times. This includes private medical doctors and personnel seeing patients. Those allowed to transport infants should have a unique and distinctive form of identification. 7. Staff will maintain security of locked doors and use swipe cards for entry into the unit. 8. Avoid posting parent and patient names where it is visible to visitors. Do not leave open charts or active computer screens where others can see them. 9. All infant/child should be transported in a crib, bassinet, wheelchair and or stretcher. Approach anyone carrying an infant in his or her arms. 10. Provide ongoing parent education promoting infant safety. Response to potential abduction: Use Code Amber-Missing Infant, Child, patient checklist as guidelines to follow for potential abduction 1. Nursing Staff a. Response to potential abduction i. Staff members will respond to the location as indicated on the designated security terminal and determine the cause of the alarm activation. ii. The entire unit should be immediately searched ( not a first response accurate baby count) iii. Notify security iv. If potential abduction is taking place the nursing staff should call 82222 and Code Amber v. If abductor and infant / child are confronted: remain calm, do not provoke anger and take every precaution to protect the infant/ child. vi. Leave the site undisturbed to preserve evidence Pg. 2 of 12
VIRTUA HEALTH MANUAL TITLE Children’s Care Manual
POLICY NAME
INFANT/CHILD SECURITY GUIDELINES & PROCEDURES
MANUAL OWNER MCH Specialty Practice Council
DATE OF ISSUE
REVIEW INTERVAL
REVIEWED / APPROVED BY: (Committees) MCH SPECIALTY PRACTICE COUNCIL
36 Months
10/2011
DATE OF LAST REVIEW 2/13, 08/14
DATE OF REVISION
EFFECTIVE DATE
MHBC: 4/99, WJHS:12/96, VIR: 5/03, 4/07, 2/08, 2/13
11/2011
vii. Additional staff will perform a count of infant/ children present on the unit as well as MBU, NICU, SCN, HORB, and Pediatrics and secure all exits. b. Missing Infant or Child i. Commence a search of most probable areas (rooms, bathrooms, storage, stairwells, ect.). Search should be thorough but quick (within 15 minutes) ii. Notify security iii. Medical records of infant/ child will be obtained and secured iv. Notify the lab to hold the infants cord blood for possible DNA identification v. Compile written description of the missing infant/ child, including photos, if possible vi. Nursing move the parents but not their belongings to a private room away from affected areas. The nurse assigned (as much as possible) to the mother and infant originally will remain with them. Pastoral care and social services may assist. vii. Have services to meet the emotional, social, and spiritual needs of the family and employees available viii. All employees are instructed to make no statements so that parents, employees, or visitors are not alarmed. Patient confidentiality must be ensured. ix. If lockdown is initiated, shift change is suspended. No one may leave the building. c. Presumed Kidnapped i. Nurses should explain the situation to all other obstetric patient/ mother with the mother and infant are together (wait word from Public Relations first) ii. Continue to provide quality care and reassurance to patients iii. Assist security, police, pastoral care, and social services as directed iv. Provide continuous support to the family of the missing child v. Visit and reassure other patients/families as possible d. Recovery/Evaluation i. Review all nursing policies relating to security/abduction ii. Make changes as needed based on review iii. Hold a group discussion session as soon as possible in which all personnel affected by the abduction are stongly suggested to attend. 2. Security Staff a. Response to potential abduction i. Security will monitor central security terminal. ii. Respond to perimeter points of the grounds to observe persons leaving and record vehicle license plate numbers. iii. Security will respond to alarm location, secure location and lock all exterior doors. iv. Note anyone with an infant/child that matches description of missing child. v. Contact the operator immediately with location and description of potential abductor if abduction confirmed. Pg. 3 of 12
VIRTUA HEALTH MANUAL TITLE Children’s Care Manual
POLICY NAME
INFANT/CHILD SECURITY GUIDELINES & PROCEDURES
MANUAL OWNER MCH Specialty Practice Council
DATE OF ISSUE
REVIEW INTERVAL
REVIEWED / APPROVED BY: (Committees) MCH SPECIALTY PRACTICE COUNCIL
36 Months
10/2011
DATE OF LAST REVIEW 2/13, 08/14
DATE OF REVISION
EFFECTIVE DATE
MHBC: 4/99, WJHS:12/96, VIR: 5/03, 4/07, 2/08, 2/13
11/2011
vi. Notify and make a report with local law enforcement and request assistance from local FBI (215-418-4000) vii. Operator will page the Faculty Disaster Recall Team viii. Once occurrence is confirmed, operator will notify Administrators on call at other Virtua Facilities and other birthing facilities in the area. ix. Secure digital recordings for 7 days prior to the date of the incident and request the same from other health care facilities in the nearby area. x. Designate separate rooms for law enforcement and media b. Missing infant or child i. initiate operator/administrator calls ii. Contact the operator immediately with location and description of potential abductor. iii. Alert operator to announce “Code Amber to the alarm location”. This will be repeated three times. 1. Operator will notify “911” and Administrator / Nursing Supervisor. 2. Operator will page the Faculty Disaster Recall Team iv. Outpatient sites call 911, and then call administration at closest division Tell operator: exact location, employee name and extension, provide information as possible describing infant, abductor, etc. Reporting employee remains at the scene to await further instructions v. Contact National Center for Missing and Exploited Children (1-800-8435678) vi. Organize a second search, which will include the entire hospital and exterior vii. When time allows, conduct interviews with anyone on the unit at the time of the incident and record names, addresses, and phone numbers. viii. Check and verify the identity of anyone who needs to enter or leave the unit. ix. All employees are instructed to make no statements so that parents, employees, or visitors are not alarmed. Patient confidentiality must be ensured x. If lockdown is initiated, shift change is suspended. No one may leave the building c. Presumed kidnapped i. Assist FBI/Police ii. Monitor and control visitors to critical areas iii. Provide security force to affected unit iv. Provide escorts as needed v. Document pertinent activity for case report d. Recovery/ Evaluation i. Alerts operator to announce the following three times: “Attention please, Attention please, Code Clear.” Termination of the Code Amber will be at the direction of the administrator on call or the ranking Official on site. ii. Provide a complete case report. iii. Determine how the infant/child was taken and take immediate steps to correct any deficiencies iv. Renew all security/abduction policies Pg. 4 of 12
VIRTUA HEALTH MANUAL TITLE Children’s Care Manual
POLICY NAME
INFANT/CHILD SECURITY GUIDELINES & PROCEDURES
MANUAL OWNER MCH Specialty Practice Council
DATE OF ISSUE
REVIEW INTERVAL
REVIEWED / APPROVED BY: (Committees) MCH SPECIALTY PRACTICE COUNCIL
36 Months
10/2011
DATE OF LAST REVIEW 2/13, 08/14
DATE OF REVISION
EFFECTIVE DATE
MHBC: 4/99, WJHS:12/96, VIR: 5/03, 4/07, 2/08, 2/13
11/2011
v. Assist law enforcement agencies as needed vi. Hold a group discussion session as soon as possible in which all personnel affected by the abduction are required to attend. 3. Public Relations a. Presumed Kidnapped i. Designate a spokesperson and press area ii. May schedule press conference iii. Instruct all employees to make no statements so that parents, employees, or visitors are not alarmed. Patient confidentiality must be ensured. iv. Consult with legal staff/hospital management concerning patient confidentiality v. Place a news release about the abduction on the facility’s website vi. Provide a written statement to address callers’ concerns over the abduction and instructions on how to handle tips or information about the abduction. vii. Activate the crisis communication plan. viii. Hold a group discussion session as soon as possible in which all personnel affected by the abduction are required to attend. 4. All Hospital Personnel a. Response to potential abduction i. Report to designated unit exit ii. Note with an infant or child that matches description of missing child. iii. Contact the operator immediately with location and description of potential abductor. iv. Attempt to stop the potential abductor if possible while maintaining safety. If unable to stop, note location of travel. v. If lockdown is initiated, shift change is suspended. No one may leave the building b. Recovery/Evaluation i. Hold a group discussion session as soon as possible in which all personnel affected by the abduction are required to attend
5. If Child in not Recovered A. Preserve the report and the interview records pertaining to the incident for a minimum of 7 years. (who would maintain the records) B. One staff member should be assigned to be primary liaison between the parents and the facility after the mother has been discharged from the facility.
Pg. 5 of 12
VIRTUA HEALTH MANUAL TITLE Children’s Care Manual
POLICY NAME
INFANT/CHILD SECURITY GUIDELINES & PROCEDURES
MANUAL OWNER MCH Specialty Practice Council
DATE OF ISSUE
REVIEW INTERVAL
REVIEWED / APPROVED BY: (Committees) MCH SPECIALTY PRACTICE COUNCIL
36 Months
10/2011
DATE OF LAST REVIEW 2/13, 08/14
DATE OF REVISION
EFFECTIVE DATE
MHBC: 4/99, WJHS:12/96, VIR: 5/03, 4/07, 2/08, 2/13
11/2011
Table 1
Pg. 6 of 12
VIRTUA HEALTH MANUAL TITLE Children’s Care Manual
POLICY NAME
INFANT/CHILD SECURITY GUIDELINES & PROCEDURES
MANUAL OWNER MCH Specialty Practice Council
DATE OF ISSUE
REVIEW INTERVAL
REVIEWED / APPROVED BY: (Committees) MCH SPECIALTY PRACTICE COUNCIL
36 Months
10/2011
DATE OF LAST REVIEW 2/13, 08/14
DATE OF REVISION
EFFECTIVE DATE
MHBC: 4/99, WJHS:12/96, VIR: 5/03, 4/07, 2/08, 2/13
11/2011
Background Based on an analysis of 230 abductions between 1983 and 2004 by the National Center for Missing & Exploited Children:
Female of childbearing age (12-50), often overweight
Compulsive, often relies on manipulation, lying, and deception
Frequently indicates she has lost a baby or is incapable of having one
Often married or cohabitating
Usually lives in the community where the abduction takes place
Frequently initially visits nursery and maternity units at more than one hospital prior to the abduction, asks detailed questions about procedures, frequently uses stairwell for escape
Usually plans the abduction but seizes any opportunity rather than targeting a specific infant
Frequently impersonates a nurse or allied health care personnel
Often becomes familiar with health care staff, work routines, and victim’s parents
Demonstrates capability to provide good care to the baby once abduction occurs
NCMEC recommends posting this information, available as a flyer on its website, out of public view at nurses’ stations and in lounges, medication rooms, and security offices. However, there is no guarantee an abductor will fit the profile.
Pg. 7 of 12
VIRTUA HEALTH MANUAL TITLE Children’s Care Manual
POLICY NAME
INFANT/CHILD SECURITY GUIDELINES & PROCEDURES
MANUAL OWNER MCH Specialty Practice Council
DATE OF ISSUE
REVIEW INTERVAL
REVIEWED / APPROVED BY: (Committees) MCH SPECIALTY PRACTICE COUNCIL
36 Months
10/2011
DATE OF LAST REVIEW 2/13, 08/14
DATE OF REVISION
EFFECTIVE DATE
MHBC: 4/99, WJHS:12/96, VIR: 5/03, 4/07, 2/08, 2/13
11/2011
APPENDIX 1 HUGS Infant Security System Hugs Tags Care and Maintenance Hugs Tag Application 1. Items Needed: 1 Hugs Tag, 1 Hugs Band of appropriate size, Hospital approved scissors. 2. Align the band with one of the tag slots and pull through 3. Guide remaining end of band around patients arm or ankle determined by age and size. 4. Tag will emit a double beep indicating a functional battery and proper band application. 5. Gently pull band ends until a secure fit is obtained. 6. Activation of the tag will be indicated at the Hugs computer by appearance of an admit pop-up box providing details on the specific tag. Tag Assessment 1. Staff will assess each Hugs tag and tag site once a shift for appropriate fit and the absence of skin irritation. Removing Hugs Tag 1. Complete steps for SUSPEND TAMPER or DISCHARGE 2. Cut band and remove Tag 3. Remove band pieces by pulling from the front of the Tag 4. Place Tag in identified receptacle for cleaning. Cleaning and Storage of Hugs Tag 1. Tags will be cleaned immediately after being removed from patient 2. Use Clorox wipe (Blue top) to clean entire surface of Tag 3. Place Tag at top of Tag dispenser
Basic Procedures Suspend Tamper Pg. 8 of 12
VIRTUA HEALTH MANUAL TITLE Children’s Care Manual
POLICY NAME
INFANT/CHILD SECURITY GUIDELINES & PROCEDURES
MANUAL OWNER MCH Specialty Practice Council
DATE OF ISSUE
REVIEW INTERVAL
REVIEWED / APPROVED BY: (Committees) MCH SPECIALTY PRACTICE COUNCIL
36 Months
10/2011
DATE OF LAST REVIEW 2/13, 08/14
DATE OF REVISION
EFFECTIVE DATE
MHBC: 4/99, WJHS:12/96, VIR: 5/03, 4/07, 2/08, 2/13
11/2011
1. The suspend tamper procedure will be used to temporarily remove a tag. A new band will be required to re-apply the tag. Failure to suspend the Tamper feature before cutting the band will result in a TAMPER ALARM. 2. The timeframe for Suspend Tamper is 4 minutes. If more time is needed the Tag will need to be discharged. 3. In the census list the Tag will be highlighted “orange”. Resume Tamper 1. The Hugs system automatically resumes monitoring the tag when the Suspend Tamper time expires. Transporting a Tag 1. The transport procedure will be used to allow an infant/tag to temporarily leave the monitored Hugs area to move to another Hugs monitored area, or visit an unmonitored area such as Radiology. 2. Select the zones for which the Tag should be signed out to or All Zones. 3. In the census the list the Tag will be highlighted “yellow” Returning a Transported Tag 1. It will be necessary to return the tag upon re-entering the Hugs monitored area. Upon completion of the Return procedure, the infant/tag will no longer be highlighted. Discharging a Tag 1. The discharge procedure will be used to remove a tag for discharge or transfer from the facility. 2. After discharge a Hugs Tag cannot be used for 30mins Alarms & Events No alarm is a false alarm Staff will respond immediately to any alarm soundings Check Tag Tightness Event 1. Verify location and safety of identified infant 2. Tighten Tag 3. Event will auto-clear Loiter Event 1. Obtain infant/tag information and exit location in the event window 2. Direct infant away from monitored exit 3. Event will auto-clear Door Ajar Event 1. Obtain exit location 2. Close identified exit 3. Event will auto-clear Pg. 9 of 12
VIRTUA HEALTH MANUAL TITLE Children’s Care Manual
POLICY NAME
INFANT/CHILD SECURITY GUIDELINES & PROCEDURES
MANUAL OWNER MCH Specialty Practice Council
DATE OF ISSUE
REVIEW INTERVAL
REVIEWED / APPROVED BY: (Committees) MCH SPECIALTY PRACTICE COUNCIL
36 Months
10/2011
DATE OF LAST REVIEW 2/13, 08/14
DATE OF REVISION
EFFECTIVE DATE
MHBC: 4/99, WJHS:12/96, VIR: 5/03, 4/07, 2/08, 2/13
11/2011
Clearing An Alarm – Use these procedures when clearing any alarm listed below 1. Follow response instructions outlined for the specific alarm 2. Login to the Hugs monitor 3. In alarm window, click to highlight the alarm to be cleared 4. Click clear 5. Click the census tab to return to viewing the census list Exit Alarm – will occur when an infant/tag comes too close or passes through an open monitored exit without being TRANSPORTED or DISCHARGED 1. NO alarm is a false alarm 2. Location will be indicated by red flashing doors 3. Clear alarm only after the identified infant’s safety has been determined. Tamper Alarm – will display when the contact between tag and band is damaged or broken. 1. An audible notification and alarm box will display on Hugs monitor 2. Clear alarm only after identified infant’s safety has been determined 3. Replace tag and band Tag Loose Alarm – will occur when tag looses contact with the patient’s skin for a specified amount of time. 1. An audible notification and alarm box will display on Hugs monitor 2. Clear alarm only after the identified infant’s safety has been determined. Low Battery Alarm – will occur when the battery of a tag becomes low. 1. An audible notification and alarm window will display at the Hugs monitor 2. Clear alarm 3. Follow facility procedure for low battery tags
APPENDIX 2 Pg. 10 of 12
VIRTUA HEALTH MANUAL TITLE Children’s Care Manual
POLICY NAME
INFANT/CHILD SECURITY GUIDELINES & PROCEDURES
MANUAL OWNER MCH Specialty Practice Council
DATE OF ISSUE
REVIEW INTERVAL
REVIEWED / APPROVED BY: (Committees) MCH SPECIALTY PRACTICE COUNCIL
36 Months
10/2011
DATE OF LAST REVIEW 2/13, 08/14
DATE OF REVISION
EFFECTIVE DATE
MHBC: 4/99, WJHS:12/96, VIR: 5/03, 4/07, 2/08, 2/13
11/2011
♥♥HUGS TIP SHEET♥♥ On Admission to the Unit
♥ upon entering your patient’s room on admission you will need the following: Hugs Tag, 2 bands, and pair of scissors (Until we are comfortable with applying tags). ♥Once in the patient room… ♥Write down Tag ID number for your reference ♥Pull the band through one end of the tag and loop it through the other end (You should hear a “Beep” to indicate the tag is connected followed by an audible cue at the Hugs monitor) ♥Once connection is made you have 2 MINS to make any adjustments to the tag (If the tag is too tight, cut the band, and start over. Please remember you only have 2 MINS to make any adjustments from the time of the INTIAL connection. ♥If you forget to bring an extra band and the tag is to tight, leave the tag as is and return to the Hugs
♥
Central Monitor. Enter the patient information based on the TAG ID # >> click on the next to the patients name >> click “SUSPEND TAMPER”. You now have 4 MINS to make any adjustments to the tag. The “SUSPEND TAMPER” function will count itself down and resume connection. ♥We recommend using the BUDDY SYSTEM until you get the hang of applying and admitting tags into the system. When you enter the patient’s room for the first time have a co-worker stand by the Hugs Central Monitor (RN, MST, US). Inform them of the tag # being applied, once connected (“child laughing”) they should enter the patient data as indicated below. Last, First Name (Ex: Smith, Boy) *(Peds/PICU: Smith, L) Zone (Pick your unit/department) Room # (Very Important) Gender ♥If you forget to enter any of the patient information at the Hugs Monitor. ♥Return to the CENSUS tab at the top of your screen and find your patient or tag # in the list ♥If you forgot to enter the patients name you will see (Ex. Hugs Tag 95) >>click on the field itself and you will be able to free text the patients name >> hit “OK”. This applies for the all the fields listed above.
Pg. 11 of 12
VIRTUA HEALTH MANUAL TITLE Children’s Care Manual
POLICY NAME
INFANT/CHILD SECURITY GUIDELINES & PROCEDURES
MANUAL OWNER MCH Specialty Practice Council
DATE OF ISSUE
REVIEW INTERVAL
REVIEWED / APPROVED BY: (Committees) MCH SPECIALTY PRACTICE COUNCIL
36 Months
10/2011
DATE OF LAST REVIEW 2/13, 08/14
DATE OF REVISION
EFFECTIVE DATE
MHBC: 4/99, WJHS:12/96, VIR: 5/03, 4/07, 2/08, 2/13
11/2011
On Discharge
♥When a patient tagged with HUGS is ready for discharge…
♥
♥Go to the HUGS Central Monitor >> find patient in census list >>click on the next to their name >> click on “DISCHARGE” >> asked to confirm discharge click “YES”. ♥Your patient will no longer be connected to the Hugs Security system. Remove tag from patient.
Cleaning & Storage
♥Once the bands have been removed from the tag, the EXPECTATION is that the RN, MST/US will clean the tag with a CLOROX Wipe (Blue Top Clorox Container) and return the tag to the TOP of the HUGS holder (white bracket) mounted on your units. Tags will remain asleep for 30mins after discharge. ♥♥♥♥PLEASE refer to the HUGS Quick Reference Guide for more helpful hints ♥♥♥♥♥
Pg. 12 of 12
